Medical Benefits Regulation

(Consolidated up to 291/2025) alberta regulation 84/2006 Alberta Health Care Insurance Act MEDICAL BENEFITS REGULATION Table of Contents 1 Definitions 2 Eligibility 3 Benefits for services in Alberta 3.1 Alternative Relationship Plans 4 Benefits for services in Canada 5 Benefits for services outside Canada 6 Included in amount of benefits 7 Conditional benefits 8 Alteration of appearance surgery 9 Specialist benefits 10 Rates set by regional health authority 11 Repeal 11.1 Expiry Definitions 1 In this Regulation, (a) “Act” means the Alberta Health Care Insurance Act ; (a.1) “Alternative Relationship Plan” means a plan referred to in section 3.1; (b) “insured medical services” means (i) all services provided by physicians that are medically required, and (ii) any other services that are declared to be insured health services pursuant to section 2 of the Act, but does not include any services that a person is eligible for and entitled to under any Act of the Parliament of Canada or under the Workers’ Compensation Act or any law of any jurisdiction outside Alberta relating to workers’ compensation; (c) “Schedule of Medical Benefits” means the Schedule of Medical Benefits prepared and published by the Department of Primary and Preventative Health Services and approved by the Minister. AR 84/2006 s1;25/2011;170/2012;158/2025;291/2025 Eligibility 2 (1) Benefits are payable in accordance with the regulations under Part 1 of the Act for insured medical services provided to a resident of Alberta. (2) Notwithstanding subsection (1), benefits are not payable for insured medical services if a declaration under section 25 of the Health Insurance Premiums Act is in effect in respect of the person who receives the services. AR 84/2006 s2;291/2025 Benefits for services in Alberta 3 (1) The benefits payable for insured medical services provided to a resident of Alberta in Alberta and the descriptions of those services are set out in the Schedule of Medical Benefits. (2) Notwithstanding subsection (1), unless otherwise approved by the Minister, the benefits payable for insured medical services provided to a resident of Alberta in Alberta are limited to the lesser of (a) the amount claimed, and (b) the rates established in the Schedule of Medical Benefits. Alternative Relationship Plans 3.1 (1) The Minister may by order establish one or more Alternative Relationship Plans whereby a physician provides an insured medical service for which the benefit is paid by the Minister other than in accordance with section 3. (2) An Alternative Relationship Plan may provide for the insured medical services to which the Plan applies, the amount of benefits payable, the manner in which the benefits are to be paid, the persons to whom benefits are to be paid, the conditions of payment and the information required to be submitted in connection with claims for the benefits. AR 25/2011 s3 Benefits for services in Canada 4 (1) In this section, “medical reciprocal agreement” means an agreement referred to in section 17(1) of the Alberta Health Care Insurance Regulation . (2) Notwithstanding any provision in this Regulation, benefits for insured medical services provided to a resident of Alberta by a physician in another province or territory of Canada that are claimed under a medical reciprocal agreement are payable (a) according to the rules established for payment of benefits in that province or territory, and (b) at the rates established by that province or territory. (3) Notwithstanding any provision in this Regulation, benefits for insured medical services provided to a resident of Alberta by a physician in another province or territory of Canada that are not claimed under a medical reciprocal agreement are determined as follows: (a) if the insured medical services are insured services under the legislation of that province or territory, the benefits are payable according to the rules established for payment of benefits in that province or territory and are limited to the lesser of (i) the amount claimed, and (ii) the rates established by that province or territory; (b) if the insured medical services are not insured services under the legislation of that province or territory, the benefits are payable according to Part 1 of the Act and the regulations made under that Part, and are limited to the lesser of (i) the amount claimed, and (ii) the rates established in the Schedule of Medical Benefits. (4) No benefit is payable for services provided to a resident of Alberta by a physician in another province or territory of Canada unless the services are insured medical services in Alberta or are claimed under a medical reciprocal agreement. AR 84/2006 s4;291/2025 Benefits for services outside Canada 5 (1) Subject to the Out‑of ‑Country Health Services Regulation, the benefits payable for insured medical services provided to a resident of Alberta by a physician outside Canada are limited to the lesser of (a) the amount claimed, and (b) the rates established by the Minister. (2) No benefits are payable for services provided to a resident of Alberta by a physician outside Canada if the services are not insured medical services in Alberta. Included in amount of benefits 6 The benefits payable for insured medical services provided to a resident of Alberta by a physician include an amount for the following: (a) performing the insured medical service; (b) administration; (c) recording of information regarding the services provided unless the recording of the information is for the purposes of a third party; (d) completing and submitting claims; (e) discussion or correspondence with a referring health care professional regarding treatment or a service to be provided to a patient directly related to managing the patient’s care, unless otherwise provided in this Regulation or the Alberta Health Care Insurance Regulation . Conditional benefits 7 Benefits are not payable for pathology services or diagnostic imaging services provided to a resident of Alberta in Alberta unless the physician that provides the insured medical service has been accredited to provide the insured medical service by the College of Physicians and Surgeons of Alberta. Alteration of appearance surgery 8 No benefit is payable with respect to a surgical procedure for the alteration of appearance performed for emotional, psychological or psychiatric reasons unless the Minister gives approval prior to the surgery being performed. Specialist benefits 9 (1) Specialist benefits for insured medical services provided in Alberta are payable in respect of a physician who (a) is authorized to use the term “specialist” in accordance with the Health Professions Act , or (b) has received an interim authorization issued by the College of Physicians and Surgeons of Alberta under that Act, indicating that the physician has completed the requirements to be authorized to use the title “specialist”. (2) Specialist benefits for insured medical services provided to a resident of Alberta in a place outside of Alberta are payable only if the physician who provided the insured medical services is accredited as a specialist in that place. AR 84/2006 s9;143/2021 Rates set by regional health authority 10 (1) The benefits payable for laboratory medicine services and pathology services provided to a resident of Alberta in Alberta are the rates determined by the regional health authority of the health region in which the services are provided. (2) The benefits referred to in subsection (1) are not payable unless the service is provided by a person authorized by a regional health authority to provide the service. Repeal 11 The Medical Benefits Regulation (AR 173/93) is repealed. Expiry 11.1 For the purposes of ensuring that this Regulation is reviewed for ongoing relevancy and necessity, with the option that it may be repassed in its present or an amended form following a review, this Regulation expires on March 31, 2031. AR 143/2021 s3 12 Repealed AR 15/2016 s2.